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Diagnosis, management and training in perineal trauma: a national survey of UK midwives

02 June 2023
Volume 31 · Issue 6



Midwives are often the only professionals to examine a women after a vaginal birth. Therefore, it is important that they are trained in the detection and management of obstetric perineal trauma. This study's aim was to establish midwives' current knowledge and training in post-birth perineal trauma, including obstetric anal sphincter injuries, in the UK.


An online national validated survey was distributed to UK midwives. There were 58 questions to assess midwives' knowledge and training. Univariable and multivariable analyses were conducted.


A total of 149 midwives participated. Only 50.3% had received training in obstetric tears. Midwives were better at classifying 3a (98.0% and 87.9% respectively) than 3b tears (79.2%, 85.9% and 84.6%) from images and descriptive text. Those who had training (P=0.02) and were a higher banding (P=0.003) were better at identifying tears.


Although midwives' knowledge of obstetric tears was good, there was room for improvement and midwives stated that they would like more training.

Perineal trauma occurs in around 85% of births (McCandlish et al, 1998). Third and fourth degree tears, also known as obstetric anal sphincter injuries, occur in 2.9% of all vaginal births (Royal College of Obstetricians and Gynaecologists, 2015), and 6% of first vaginal births (Thiagamoorthy et al, 2014) in the UK. Some women may not experience symptoms after obstetric anal sphincter injuries, but up to 61% of women will experience anal incontinence, even after primary repair (Sultan and Thakar, 2007). Women with anal incontinence may experience emotional, social and psychological consequences, including embarrassment, isolation and a loss of dignity (Keighley et al, 2016).

As midwives assist with most vaginal births in the UK, they may be the only healthcare professional to examine a woman after birth. Therefore, training in the diagnosis of perineal trauma, including obstetric anal sphincter injuries, is essential. The Nursing and Midwifery Council's (NMC, 2019) standards of proficiency for midwives state that midwives must demonstrate, at qualification, the skill to ‘undertake repair of 1st and 2nd-degree perineal tears, and refer additional trauma’. Midwifery courses at UK universities vary in their content on perineal trauma, resulting in wide variation in training. There are some hands-on training courses in obstetric anal sphincter injuries available to midwives (Croydon Urogynaecology and Pelvic Floor Reconstruction Unit, 2023; Perineal Course, 2023), but they are not mandatory.

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